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ACNP III Final Exam: Questions With Solutions
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ACNP III Final Exam: Questions With Solutions
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ACNP III Final Exam: Questions With SolutionsEtiology of Immunosuppression Right Ans - • Primary immunodeficiency
◦ Genetic lymphocyte deficiency
• Secondary immunodeficiency
◦ Acquired
▪ Malignancies
▪ Drugs
▪ Viruses
▪ Infections
▪ Malnutrition
Who Is Immunosuppressed? Right Ans - • Is there a clear-cut patient
population?
◦ Established diagnosis
▪ Primary (genetic) immune disorder
▪ HIV/AIDS
▪ Chemotherapy regimen
• Who else should you consider?
◦ At-risk populations: multiple partners without condoms, IVDU, work
exposure, travel to exposed places.
◦ Chronic disease: COPD, lupus, RA, transplant, etc.
◦ Critically ill: Sepsis, etc.
Recognizing Immunosuppression: Patient History Right Ans - • Concurrent
disease
• Current medications
• Weight loss
• Occupational history
• Travel history
• Social history
◦ IV drug use
◦ ETOH history
◦ Sexual history
• Family history
• Constitutional sx
◦ Fatigue
◦ Weight loss
◦ Night sweats
,◦ Malaise
• Hematologic sx
◦ Easy bruising
◦ Bleeding
Recognizing Immunosuppression: Physical Examination Right Ans - • Signs
of chronic disease?
• Palpable lymphadenopathy?
• Signs of chronic steroid therapy?
• Potential ports of entry for infection?
• Nutritional status?
Investigation of Immune Deficiency Status Right Ans - • No single definitive
test!
• CBC with differential
• Biochemical markers: CRP, ESR, TREM-1, procalcitonin
• Other tests of immune function: T-lymphocytes, ANC, complements,
antibodies
• Remember:
◦ Immunosuppression is not an all-or-nothing phenomenon; there are degrees
of immune compromise
Management of immunocompromised patient Right Ans - •
Assess/evaluate fever if present
• Send cultures as quickly as possible with goal of starting broad spectrum
antibiotic coverage within 1 hour of identification of suspected infection
• Choice of antibiotic regimen?
◦ The apparent site of infection; the working diagnosis
◦ The most likely infecting organism(s); related to the above
◦ Local resistance patterns
◦ Preexisting organ dysfunction
◦ Patient allergies
◦ Previous antibiotic exposure
◦ Degree of immunosuppression
• Determine underlying diagnosis as quickly as possible and treat
◦ Site
◦ Organism
• Protect the patient from further insults
• Prevention measures
,◦ Patient/family education
◦ Staff education
◦ ICU design
Antiinfective Considerations for ALL IMMUNOSUPPRESSED PATIENTS
Right Ans - • When starting empiric therapy or narrowing the spectrum of
antibiotic therapy in ANY PATIENT with IMMUNOCOMPROMISE, make sure
the antibiotic(s) you are ordering is BACTEROCIDAL. Bacteriostatic antibiotics
require a functional immune system to work.
• Consider adding an antifungal agent to the empiric therapy regimen for any
immunosuppressed patient—azole antifungals may not be effective if the
disease is disseminated or caused by more resistant species.
• Candida infections are common in critically ill patients (candida often lives
on the skin) and can result in central-line associated blood stream infections
(CLABSI). Azole antifungals typically cover most candida (yeast) strains.
• Candida is typically cleared by the bod Only approximately 50% of candida
BSIs are identified on blood cultures.
• Candida BSIs are considered an independent risk factor for mortality.
• Some patients can be infected with more resistant yeasts such as C. galbrata
& C. krusei.
• Echinocandins (such as micafungin & voriconazole) are used to treat
disseminated candida (candidemia) and are fungicidal against C. galbrata and
C. krusei, and are active against Aspergillus spp. (usually airborne spread can
lead to pulmonary cavitation—known as aspergillomas, but can cause
endocarditis, etc.).
• Amphotericin B is usually reserved for more severe infections (e.g.
tropicalis, C. krusei, Cryptococcus neoformans, Blastomyces dermatitidis,
Histoplasma capsulatum, molds, mucorales, etc.
Induction Immunosuppression only INPATIENT: Adverse Effects Right Ans
- • Cytokine release syndrome: T cells cause SIRS type of reaction. Tx:
Tocilizumab, an anti-IL6 monoclonal and corticosteroids.
• Anaphylaxis
• Serum sickness
• Pancytopenia
• Flash pulmonary edema
• Seizures
• Increased long-term-risk infections and malignancy
, Maintenance Immunosuppression Right Ans - • Goal is to promote graft
survival and prevent rejection
• Triple therapy
• Dosage titration
◦ Levels—side effects—clinical status
• Balance risks: Rejection—infection
• Duration?
Maintenance Immunosuppression: Triple Therapy Right Ans - •
Calcineurin inhibitors
◦ Cyclosporine or tacrolimus
• Purine synthesis inhibitors
◦ Azathioprine or mycophenolate mofetil (MMF)
◦ Consider sirolimus or everolimus
• Steroids
Rejection Right Ans - • Hyperacute
◦ Immediate organ dysfunction, necrosis, failure
◦ ABO/HLA, preformed antibodies, previous exposures
◦ Common in the first year after transplant
• Acute
◦ Abrupt, commonly in first year after transplant
◦ Usually treatable but predisposes to chronic
◦ Major cause of mortality/morbidity in first year after transplant
• Chronic
◦ Diffuse and progressive thickening and fibrosis
◦ Poorly understood
◦ Microvasculature and functional components of graft
Rescue Immunosuppression for rejection Right Ans - • Initiate at time of
suspected or confirmed rejection
• Goal is to arrest active rejection
• Pulse steroids vs. antilymphocyte antibodies
• Augment or alter maintenance "cocktail"
• Plasmapheresis
Opportunisitic Organisms Right Ans - • CMV, VZV, HSV
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